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PROVIDENCE, R.I. -- Almost one-third of the time, doctors miss cases of head injuries caused by abuse to infants and small children, says a study in this week's Journal of the American Medical Association.

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Diagnosing head trauma from impacts or shaking can be difficult in the absence of a history of child abuse. Head trauma is also easy to miss if no obvious symptoms are present. But physicians must consider that such injuries may be inflicted on infants and young children who present non-specific signs of abuse, say the study authors.

"In some case, the parents knew that someone had hurt the baby and they didn't tell the doctors," said Carole Jenny, M.D., the study leader and professor of pediatrics in the Brown University School of Medicine. "In other cases, parents didn't have a clue. Abuse may have come at the hands of a babysitter, grandparent or boyfriend. We need to do a better job. Let's be more aware of this diagnosis."

The study showed that 54 (31.2 percent) of 173 children with abusive head trauma, such as hemorrhaging, fractures and brain contusions, had been seen by physicians after suffering the injuries but that the diagnosis was not recognized. For these 54 children, the average time to the correct diagnosis was about seven days. All of the children in the study were under the age of three.

Abusive head trauma was more likely to be unrecognized in very young white children from two-parent families and in children without respiratory problems or seizures.

"If these people walk in and physicians don't think that abuse occurred, then there may be subtle biases in terms of decision-making by physicians," said Jenny, who also heads ChildSafe-The Child Protection Program at Hasbro Children's Hospital.

In seven of the 54 children with unrecognized abusive head trauma, the misreading of radiological studies, such as CT scans and skeletal or bone X-rays, contributed to a delay in diagnosis. Jenny suggests that pediatric radiologists be the ones who read and interpret images of infants and children. "Pediatric radiology is a specialty unto its own," she said. "It is not the same thing as reading an image of an adult."

Fifteen (27.8 percent) of the 54 children with unrecognized abusive head trauma were reinjured after the missed diagnosis. Twenty-two (40.7 percent) experienced medical complications related to the missed diagnosis. Twenty (37 percent) had other signs of injuries to their face or scalp such as bruises. Four of five deaths in the group might have been prevented by earlier recognition of abuse, said the study authors.

Physicians must be more attentive to general signs of abuse such as scrapes and scratches, Jenny said. She suggested that doctors perform more mindful exams of young children, particularly if their faces are bruised. "Retinal hemorrhaging, for example, is a sign of abuse, and should be looked for as part of a careful exam," Jenny said.

Symptoms of head injuries in infants, such as irritability, vomiting or low-grade fever, are also indicators of other conditions. Because there is no complex of neuro-phenomena to alert a physician to abusive head trauma in infants, the authors call for more research on ways to screen for head injuries in infants and children.

One avenue of research would be to develop and test serum markers to tell if a young child has been injured through shaking or impact, Jenny said.

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